What are the treatment options for acne?

Acne Treatment

First-Line Treatment Approach

For mild acne, start with adapalene 0.1-0.3% gel or tretinoin 0.025-0.1% cream/gel once nightly combined with benzoyl peroxide 2.5-5% once daily; for moderate-to-severe inflammatory acne, add doxycycline 100 mg once daily or minocycline 100 mg once daily, always with concurrent benzoyl peroxide to prevent resistance. 1, 2

Treatment Algorithm by Severity

Mild Acne (Comedonal or Minimal Inflammatory Lesions)

• Topical retinoid + benzoyl peroxide is the foundation of treatment 1, 2
• Apply adapalene 0.1% gel (available over-the-counter) or 0.3% gel once nightly to completely dry skin 1
• Alternatively, use tretinoin 0.025%, 0.05%, or 0.1% cream or gel once nightly, starting with lower concentrations in sensitive skin and titrating up as tolerated 1
• Add benzoyl peroxide 2.5-5% gel, cream, or wash once or twice daily 1
• Adapalene is more photostable than tretinoin and can be used with benzoyl peroxide, while some tretinoin formulations should not be combined with benzoyl peroxide due to photolability 1, 2
• For patients with post-inflammatory hyperpigmentation, azelaic acid 15-20% gel or cream applied twice daily is particularly useful 1, 2

Moderate Acne (Mixed Comedonal and Inflammatory Lesions)

• Fixed-dose combination of topical retinoid + benzoyl peroxide as first-line 2
• Add topical antibiotics (clindamycin 1% or erythromycin 2-3%) applied twice daily, but never as monotherapy due to resistance risk 1, 2
• Fixed-combination products (erythromycin 3%/BP 5%, clindamycin 1%/BP 5%, clindamycin 1%/BP 3.75%) enhance compliance 1, 2
• Topical dapsone 5% gel is particularly effective for inflammatory acne in adult females and does not require glucose-6-phosphate dehydrogenase testing 1, 2

Moderate-to-Severe Inflammatory Acne

• Triple therapy: oral antibiotics + topical retinoid + benzoyl peroxide 1, 2
• Doxycycline 100 mg once or twice daily with food (strongly recommended with moderate evidence) 1, 2
• Minocycline 100 mg once or twice daily (conditionally recommended with moderate evidence) 1, 2
• Limit systemic antibiotics to 3-4 months maximum to minimize bacterial resistance development 1, 2
• Always combine oral antibiotics with benzoyl peroxide to prevent resistance 1, 2
• For temporary benefit in severe inflammatory acne, oral corticosteroids can be used while starting standard treatment 2

Severe Recalcitrant Nodular Acne

• Oral isotretinoin is the treatment of choice, as it is the only drug affecting all four pathogenic factors of acne 1, 3
• Start with 0.5 mg/kg/day and increase to 1.0 mg/kg/day as tolerated, targeting a cumulative dose of 120-150 mg/kg 1
• For moderate treatment-resistant acne, 0.25-0.4 mg/kg/day can be used with equal efficacy and fewer side effects 1
• Isotretinoin should be used only as second-line therapy after failure of conventional treatments due to serious potential side effects 4, 3
• Intralesional triamcinolone acetonide injection provides rapid improvement for larger nodular lesions, though local atrophy and systemic absorption may occur 5

Hormonal Therapy for Female Patients

• Combined oral contraceptives are effective for inflammatory acne in females and should be used at standard contraceptive dosing per product labeling 1, 2
• Spironolactone 25-200 mg daily is useful for hormonal acne patterns or antibiotic-intolerant patients, without need for potassium monitoring in healthy patients 1, 2
• In a meta-analysis of 32 randomized trials, combined oral contraceptives reduced inflammatory lesions by 62% at 6-month follow-up 6

Maintenance Therapy After Clearance

• Continue topical retinoid once nightly indefinitely after achieving clearance to prevent recurrence 1, 2
• Add benzoyl peroxide 2.5-5% once daily if needed for more severe baseline disease 1, 2
• Maintenance therapy with topical retinoids minimizes potential for relapse, which is part of the natural history of acne 7

Additional Topical Options

• Clascoterone 1% cream applied twice daily is a newer topical antiandrogen, conditionally recommended due to high cost 1
• Salicylic acid 0.5-2% is an over-the-counter comedolytic agent with limited clinical trial evidence 2
• Topical tea tree oil has shown effectiveness comparable to benzoyl peroxide but with better tolerability in clinical trials 5

Physical Modalities

• Glycolic acid and salicylic acid chemical peels may be helpful for noninflammatory (comedonal) lesions, though multiple treatments are needed and results are not long-lasting 5
• Some laser and light devices (pulsed dye laser, KTP laser, photodynamic therapy) may be beneficial, but additional studies are needed 5
• Limited evidence exists for most physical modalities, and large multicenter trials are lacking 5, 8

Special Considerations

Back Acne

• Treatment follows the same severity-based approach as facial acne 2, 9
• Adapalene 0.1% gel is available over-the-counter for mild back acne 9
• Benzoyl peroxide can bleach clothing and bedding; wear old or white clothing when applying to back 9

Pediatric Patients

• Topical adapalene, tretinoin, and benzoyl peroxide can be safely used in preadolescent children 2
• Use in patients ages 12-17 years should be given careful consideration, especially when metabolic or structural bone disease exists 4
• Increased incidence of back pain, arthralgia, and myalgia occurs in pediatric patients compared to adults 4

Dietary Considerations

• No specific dietary changes are recommended in routine acne management 5
• Emerging evidence suggests high glycemic index diets may be associated with acne 5
• Limited evidence suggests some dairy, particularly skim milk, may influence acne 5

Critical Pitfalls to Avoid

• Never use topical or oral antibiotics as monotherapy - resistance develops rapidly without concurrent benzoyl peroxide 1, 2
• Never extend oral antibiotics beyond 3-4 months without re-evaluation, as this dramatically increases resistance risk 1, 2
• Do not stop treatment once acne clears - maintenance therapy is essential to prevent relapse 2, 9
• Do not underestimate severity when scarring is present - this warrants more aggressive treatment 2
• Topical retinoids cause photosensitivity; recommend daily sunscreen use 2, 9
• Patients on isotretinoin experiencing visual difficulties should discontinue treatment immediately and have ophthalmological examination 4
• Decreased night vision can occur with isotretinoin and may persist after discontinuation; warn patients about driving at night 4

Psychological Impact

• Acne can cause permanent physical scarring and negatively affect quality of life, self-image, and has been associated with increased rates of anxiety, depression, and suicidal ideation 6
• Effective acne treatment can improve the emotional outlook of patients 5
• The psychological effects may be profound and should influence treatment decisions toward more aggressive therapy when appropriate 5, 2